Introduction
Digital sensors and devices are in widespread use to monitor many physiologic functions. They provide indicators and parameters for early warning scores for patients in acute health systems, whether as telemetry, continuous pulse and oximetry, urine output, and other sensor systems. In many parts or the world, such monitoring systems are in widespread use, but their use could be expanded right now, to include other settings; where the patient is in a step-down unit, or ambulatory care facility, or even at home. In a similar fashion to their use in hospitals, such digital sensors can be used to provide an objective measure of a subject’s status and also provide indicators of whether or not a patient is deteriorating or improving. These could be used, and would be of utility to monitor patients with chronic conditions or to monitor patients postoperatively after discharge from a health facility; enabling early intervention, and perhaps improving patient outcomes and reducing hospital readmissions.
There are opportunities to use telehealth tools to engage patients with their health and the health system after they leave the hospital, and even to prevent admission to hospital. At the University Of Michigan Department Of Urology, an automated chat bot was used to provide postoperative instructions to patients after ureteroscopy ( ). While such work is an area of ongoing research, healthcare providers must be careful that they don’t neglect to interact with their patients, and defer important postoperative care (and indeed preoperative care and consenting), to automated digital tools. Such misuse of technology may significantly impact on patient outcomes and act to undermine the physician–patient relationship; replacing it with something more akin to a customer–provider relationship. Medical ethicists have long decried the impact of economic pushes and pulls in medical practice and the challenges they provide to the physician–patient relationship ( ) ( ). Using telemedicine to engage patients after they leave the hospital or doctor’s office is an area of ongoing research, and has significant potential to improve the value of healthcare by providing information and reassurance to patients. This chapter will focus more on systems, strategies, and devices that decrease the distance and barriers, and enable ongoing engagement with their physician.
Challenges in remote patient monitoring (RPM) include making patients comfortable with the technology and the constant monitoring. A large component of this is patient education, which in many settings, is largely performed by those coordinating care, whether physicians, nurses, or allied health professionals. This window for patient education, often is best suited to take place when the patient is admitted to a healthcare facility, and they can become familiar with the device and troubleshoot any issues that may arise. This is preferable to the scenario, where patient discharge is imminent, and the device is handed over to the patient, with minimal time for them to interact and become comfortable with it. With time though, it should be the case that minimal to no further patient education is required, and that such monitoring systems are either completely autonomous or are innately intuitive, and require minimal to no conscious user input, so that anybody can benefit from their use.
Other challenges to RPM range from upfront costs and capital expenditure for suitable devices, licenses, and infrastructure to reimbursement for telemonitoring. There is due concern that the digital divide will become more apparent and that while telemonitoring may help reduce some disparities (for example, rural vs. urban dwellers), other disparities may be magnified. The field is very much in its infancy, and for more complex conditions, the field is still identifying optimal patient groups that would benefit. However, for routine care and preventing readmissions, the case can be made that all that is missing is the will to implement telemonitoring.
Benefits of remote monitoring
Prevent readmissions
Almost 20 years ago, the Veterans Health Administration, a nationalized healthcare service in the United States, introduced a national home telehealth program which is known as “Care Coordination/Home Telehealth” (CCHT). The Veterans Heath Association is the largest integrated healthcare system in the United States of America and provides care to over nine million military veterans at over 1200 healthcare facilities.
The CCHT coordinates the management of chronic conditions and was launched with the objective of reducing and preventing unnecessary hospital admissions. The service is a small part of the overall Veteran Health Administration; the CCHT was initially staffed by over 5000 trained staff, a small fraction of the over 350,000 employed by the Veteran Health Affairs. The CCHT systematizes the implementation of health informatics, home telehealth, and disease management technologies. In a study published on data obtained from 17,025 patients enrolled in CCHT, there was a 25% reduction in number of bed days of care, 19% reduction in hospital admissions, and a mean satisfaction score rating of 86% ( ). The impact of this work is all the more meaningful to patients, especially those who wish to remain in their own home and live independently. During this study which was conducted between July 2003 and December 2007, the cost of this service was $1600 per annum. This pales in comparison with the figure reported by the United States Government Accountability Office in a 2020 report on Veterans Affairs (VA) Health Care, which reported the average cost per day for veteran’s care as $268 in a community nursing home, and $1074 per day in a VA community living center. This is all the more considerable, when VA data show that the number of veterans receiving long-term care in VA funded programs was 530,327 in 2018, a sizable portion of the over nine million veterans the Veteran Health Administration provides care to. Over 5% of veterans discharged from hospital are discharged to a long-term care facility ( ). This is a sizable burden, and CCHT and its remote monitoring program were able to reduce the number of hospital days by ∼25% in this population with high healthcare utility, for a cost between 1/60th and 1/240th of long term care ( Table 8.1 ) .
| Cost per day | Cost per month | Cost per year | |
|---|---|---|---|
| VA CCHT | $ 4.38 | $ 133.33 | $ 1600.00 |
| VHA home-based primary care services | $ 35.95 | $ 1093.42 | $ 13,121.00 |
| Community nursing home | $ 269.00 | $ 8182.08 | $ 98,185.00 |
| VA community living center | $ 1074 | $ 32,667.50 | $ 392,010 |
CCHT’s program demonstrated very tangible benefits, and was received positively by the majority of the patients to whom it was offered. Only 10% of over 17,000 patients it was offered to, declined to take part in the program. The high patient satisfaction of the CCHT program in the United States is consistent with other programs elsewhere around the world, from Europe to Asia ( ; ).
Improve patient care
An often-overlooked performance indicator is patient access. Patients who are otherwise unable to access, or have limited access to care, are by virtue of not having access, excluded from the metric. When considering anecdotes, discussions and studies on remote patient monitoring, keep in mind that much of the existing experience and data, only accounts for those who have already had access, and may not be representative of all patients.
Telemonitoring and stable disease clinics
Boyd Viers et al. conducted a randomized and controlled trial assessing telehealth clinics compared with in-person clinics in patients who had undergone radical prostatectomy. In total, 70 patients were randomized and 55 completed their visit. Nonattendance was 25% (9/36) for the in-person visit, and 18% (6/34) for the telehealth clinic ( ).
In this study, they considered efficiency as total time spent on patient care, and found no difference between either modality (mean 17.9 vs. 17.8 min, 95% CI 5.9 to 5.6; P = .97). The total clinician–patient contact time (12.1 vs. 11.8 min, 95% CI 4.2 to 3.5; P = .85), and patient wait time (18.4 vs 13.0 min, 95% CI 13.7 to 3.0; P = .20), were also no different between the study arms.
Furthermore, there was no difference in patient satisfaction in the telehealth group ( n = 21/24, 88%) compared with the in-person group ( n = 20/22, 91%; P = .70). Uniquely, Viers et al. also recorded clinician satisfaction, with 88% of telehealth and 90% of in-person clinic urologists reporting “very good” or “excellent” ratings. Most (88%) of the telehealth patients (21/24), and 73% of patients in the in-person group (16/22), strongly agreed (Likert scale 1–7), that they could be seen without physical examination for every appointment, addressing a common telehealth concern.
However, as well as power limitations, there was a risk of selection bias, as only 24% (70/295) of screened men were randomized. After prescreening, reasons for noneligibility included 70/155 patients (45%) who declined (reasons unstated), 25 patients (16%) lacking capable technologies, 15 patients (10%) uncomfortable with a telehealth visit, and 15 patients (8%) requesting in-person consultation for medical reasons, limiting its generalizability. Finally, the end totals for the telehealth and in-person groups decreased to 24 and 22, respectively (i.e., nine men were not included); ideally the authors could have adopted an intention-to-treat analysis. In a Scottish study of a nurse-led prostate cancer follow-up clinic delivered by telehealth, , surveys were sent to 302 men. Eligibility criteria included patients if they had prostate-specific antigen (PSA)-stable disease, were a minimum of 2 years postradiotherapy, and had been seen already in an in-person clinic for ≥6 months. Patients were followed-up every 6-months for 3 years, then annually for 5 years, and then reviewed at 10 years if there were no consecutive PSA rises. The study protocol included that the clinical nurse specialist met weekly with an oncologist to discuss patients with PSA rises. As part of this study, patients visited their general practitioner (GP) for laboratory investigations every 6 months, and were informed of results by letter from the reviewing clinical nurse specialists (along with their GP). In this study, Robertson et al. reported that 50 in-person appointments were saved per month following the introduction of this telehealth delivered follow up program. Surveys were performed to assess patient satisfaction with this service, and a total of 191 surveys (63.2%) were returned. These showed that 98.4% of men were happy with the new telehealth service, and 98.8% felt “well supported” by it. This study does have it’s limitations though, and the publication does not provide patient demographics, nor does it provide data sufficient to explain how 50 in-person specialist appointments were saved per month.
Wearables and devices
Wearable devices refer to small electronic devices that are worn on bodies and can often take the form of watches, rings, glasses or are integrated into an item of clothing. They are portable and convenient, and sometimes include computing power on-board the device itself, but do not necessarily do so. Wearables in medicine are not a modern phenomenon, as the first wearable hearing aids date back to 1800.
Current technology is primed to enable greater innovation and utilization of these devices and technologies in urology, as there is widespread availability of sensors including: accelerometers, altimeters, digital cameras with charge coupled devices (CCD), electrical capacitors, microphones, infra-red pulse oximeters and photoplethysmography, Bluetooth proximity sensors, pressure sensors, and thermometers integrated into digital devices from cell phones, smartwatches, smart jewelry, and sensors embedded in clothing ( ).
Remote monitoring: uroflow and voiding diaries
CarePath have developed a device which can be used by both men and women to record urine output and record uroflow rates. The device communicates with a smart phone and provides the sensor technology required to record void-related data—namely uroflow and voided volume. Data are connected to a cloud server where flow rate and volume calculations are performed and stored in a HIPAA-compliant fashion, as per the device manufacturer. CarePath recommend that the patient use the device every time that they void urine, and that males and females be seated to use the device. CarePath state that information gathered on the first day of use is discarded as the patient becomes familiar with the device.
The system comes with a number of components and maybe cumbersome and “involved” for many patients. The device itself needs some basic assembly before use and has reusable and disposable components. The CarePath device handle is reusable and contains a rechargeable battery. This needs to be attached to a disposable component, which receives the urine flow. There is also a base station that also acts as a charging station for the handheld device and a mobile app to which the device must be paired in order to communicate to the cloud servers that process the data and maintain a voiding diary.
The device and its use does require some setup and manual dexterity to assemble the device before each use, as well as holding the device handle and correctly orienting it as the patient sits for each urine void, and this may be problematic for some ( Fig. 8.1 ).
